NEUROCOGNITION AND NEUROLOGICAL SOFT
SIGNS IN CHILDREN WITH ATTENTION DEFICIT
HYPERACTIVITY DISORDER
Dissertation submitted to theTAMIL NADU DR. M. G. R. MEDICAL UNIVERSITY
in part fulfillment of the requirements for
M. D (PSYCHIATRY)
BRANCH XVIII
APRIL 2015MADRAS MEDICAL COLLEGE
CERTIFICATE
This is to certify that the dissertation titled, “Neurocognition and
neurological soft signs in children with attention deficit hyperactivity
disorder”, submitted by Dr.KOMAL. J, in partial fulfillment for the award of
the MD degree in Psychiatry by the Tamil Nadu Dr. M. G. R. Medical
University, Chennai, is a bonafide record of the work done by him in the
Institute of Mental Health, Madras Medical College during the academic year
2012 – 2015.
DIRECTOR DEANInstitute of Mental Health Madras Medical College
Chennai Chennai
DECLARATION
I, Dr. KOMAL.J, solemnly declare that the dissertation titled,
“Neurocognition and neurological soft signs in children with
attention deficit hyperactivity disorder” is a bonafide work done by me
at the Madras Medical College, Chennai, during the period from Aug
2014 - Oct 2014 under the guidance and supervision of Dr.
JEYAPRAKASH R. MD, DPM, Professor of Psychiatry, Madras Medical
College.
The dissertation is submitted to The Tamilnadu Dr. M. G. R.
Medical University towards part fulfilment for M.D. Branch XVIII
(Psychiatry) examination.
Place:
Date: Dr.
KOMAL J
ACKNOWLEDGEMENTS
I sincerely thank Prof. Dr. Vimala R, MD, Dean, Madras
Medical College for permitting me to conduct this study.
I thank Professor Dr. R. Jeyaprakash, M.D., D.P.M., Director,
Institute of Mental Health, Chennai for his encouragement, help and
guidance.
I thank my Guide, Professor Dr. A. Kalaichelvan, M.D.,
D.P.M., Department of Psychiatry, Madras Medical College for his
encouragement and valuable suggestions.
I am grateful to my Professor Dr. Shanthi Nambi, MD,
Department of Child Psychiatry, Institute of Child Health, Chennai for
the support and guidance in initiating and conducting the study.
I thank my Co- guide, Dr. Amali Victoria, M.D., Assistant
Professor, Institute of Mental Health for her continuous guidance and
help.
My sincere thanks are due to all the Professors and Assistant
Professors of Institute of Mental Health for their encouragement and
frequent inputs. I thank my mentor Dr. Vimal Dhoshi, M.D., Assistant
Professor, Department of Child Psychiatry, Institute of Child Health,
Chennai for the guidance throughout the course and study.
I finally acknowledge and thank all my colleagues and the
participants of this study for their kind cooperation.
CONTENTS
S.No Title Page No.
1 Introduction 01
2 Review of Literature 05
3 Aim 48
4 Objectives 50
5 Methodology 53
6 Statistical Analysis 59
7 Results 61
8 Discussion 88
9 Conclusion 98
10 Bibliography 102
11 Annexures 112
ABSTRACT
Context: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental
disorder with wide repercussions. Since it is etiologically related to delayed maturation,
neurocognition and neurological soft signs (NSS) could be a tool to assess this. Further the
correlation of NSS and neurocognition with severity of ADHD and presence of Specific
Learning Disability (SLD) would give further insight into it.
Aims: To study neurological soft signs and neurocognition in children with ADHD and to
correlate NSS and neurocognition with severity of ADHD and with co morbid Specific Learning
Disability.
Settings and Design: The study was carried out in Institute of child health, Department of Child
Psychiatry, Madras Medical College. It was a cross-sectional single interview study.
Materials and Methods: 40 consecutive children diagnosed as having ADHD in each group were
assessed for the presence of neurological soft signs using Revised Physical and Neurological
Examination soft Signs scale (PANESS) and neurocognition using Trail Making Test, Stroop
Test, Verbal Fluency, Verbal N Back Test and Continuous Performance Test. The ADHD was
assesses by SNAP IV scale.
Statistical Analysis: The data was analyzed using the t-test, chi-squared test and Pearson’s co-
relational analysis.
Results and Conclusions: Neurological soft signs were more in ADHD with SLD, especially
timed movements. As the severity of ADHD increased, neurological soft signs increased in
numbers. ADHD with SLD performed poorly in attention, speed of processing and working
memory and the performance worsened with increasing ADHD severity, especially inattention
severity.
Key words: Attention deficit hyperactivity disorder, neurological soft signs, specific learning
disability
AIM
AIM
To study the neurocognition, neurological soft signs in children
with ADHD and the correlation of neurocognition, neurological soft signs
to type and severity of ADHD and with the co-morbidity of specific
learning disability.
OBJECTIVES
OBJECTIVES
1. To assess the neurocognition and neurological soft signs in ADHD
children with and without SLD.
2. To find the correlation between neurocognition and severity of
ADHD with and without SLD
3. To find the correlation between neurological soft signs and severity
of ADHD with and without SLD
NULL HYPOTHESIS
1. There is no difference between the neurocognition and neurological
soft signs in ADHD children with and without SLD.
2. There is no the correlation between neurocognition and type,
severity of ADHD with and without SLD
3. There is no the correlation between neurological soft signs and
type, severity of ADHD with and without SLD
METHODOLOGY
METHODOLOGY
Sample Selection
The study is a cross sectional observational study to be conducted
in Department of Child Psychiatry, Institute of child health, Chennai.
Ethical committee approval was obtained from Madras Medical College
ethics committee. 40 consecutive children with diagnosis of ADHD with
SLD and 40 consecutive children without SLD attending Child
Psychiatry outpatient department are taken up for further evaluation.
Diagnosis of ADHD and SLD is made according to MINI KID. All the
children, taken up for study are examined after obtaining due consent
from parent and assent from children.
METHODOLOGY
Inclusion criteria
1. Age 6-12 yrs.
2. IQ > 70 percentile
Exclusion Criteria
1. Diagnosis of Mental Retardation, Seizure Disorder and other
psychiatric or physical illness with obvious neuropathology.
2. Not consenting for study
METHODOLOGY
Materials:
1. Semi Structured Proforma for socio demographic profile and risk
factors
2. MINI KID
3. Ravens Coloured Progressive Matrices
4. ADHD SNAP IV
5. NIMHANS LD battery
6. PANESS (Physical & Neurological Evaluation for Soft Signs)
7. Neuropsychological Assessment
Executive Function – Stroop Test, MT A & B
Attention: category fluency, continuous performance test
Working Memory – Verbal N Back Test
MINI KID
The Mini-International Neuropsychiatric Interview (M.I.N.1.) is a short
structured diagnostic interview developed jointly by psychiatrists and
clinicians in the United States and Europe. for DSM-IV and ICD-IO
psychiatric disorders. With an administration time of approximately 15
minutes it was designed to meet the need for a short but accurate
structured psychiatric interview for multicenter clinical trials and
epidemiology studies and to be used as a first step in outcome tracking in
nonrescarch clinical settings. The MINI-KID generates reliable and valid
psychiatric diagnoses for children and adolescents and does so in a third
of the time as the K-SADS-PL.
SNAP IV
The SNAP-IV Rating Scale is a revision of the Swanson, Nolan and
Pelham (SNAP) Questionnaire (Swanson et al, 1983). The items from
the DSM-IV (1994) criteria for Attention-Deficit/Hyperactivity Disorder
(ADHD) are included for the two subsets of symptoms: inattention (items
#1-#9) and hyperactivity/ impulsivity (items #11-#19). Also, items are
included from the DSM-IV criteria for Oppositional Defiant Disorder
(items #21-#28) since it often is present in children with ADHD. Items
have been added to summarize the Inattention domain (#10) and the
Hyperactivity/Impulsivity domain (#20) of ADHD. Two other items
were added: an item from DSM-III-R (#29) that was not included in the
DSM-IV list for ODD, and an item to summarize the ODD domain (#30).
The SNAP-IV is based on a 0 to 3 rating scale: Not at All = 0, Just A
Little = 1, Quite A Bit = 2 and Very Much = 3. Subscale scores on the
SNAP-IV are calculated by summing the scores on the items in the subset
and dividing by the number of items in the subset. The score for any
subset is expressed as the Average Rating-Per-Item.
PANESS
PANESS is a Revised Physical and Neurological Examination for soft
Signs scale by Martha Denckla. It is used for physical and neurological
soft signs. It can be used for children and adolescents. It is an
observational scale having 21 questions covering gait, stance, laterality,
quality of rapid movements, impersistence score, involuntary movement
score, repetitive speed of movement score, and sequenced speed of
movement score, asymmetrical movement score. It assesses in terms of
laterality, timed and untimed motor movements. It has been found to have
adequate test retest reliability, inter-rater reliability, and internal
consistency. The PANESS is particularly useful for assessment of motor
speed in children because it is brief, minimizes the need for equipment,
provides lateralized data, and is applicable to children as young as 5
years.
STATISTICAL
ANALYSIS
STATISTICAL ANALYSIS
1. Comparison of sociodemographic details by chi-square test and t-
test.
2. Comparison of risk factors by chi-square and t-test, if appropriate.
3. Comparison of ADHD severity by t-test
4. Comparison of neurological soft signs using t-test
5. Comparison of neuropsychological functioning by t-test
6. Correlation between ADHD severity and neuropsychological
performance by Pearson correlation
7. Correlation between ADHD severity and neurological soft signs by
Pearson correlation
8. Comparison of two correlation factor by fisher r to z transformation
All statistical analysis was done using SPSS version 20 statistical
software. Level of significance was kept at p<0.05 and highly significant
if p<0.01
RESULTS
RESULTS
The present study compares the risk factors, soft neurological signs and
neuropsychological functioning among two groups of ADHD children.
One group is with comorbid SLD and other group is without SLD.
SOCIODEMOGRAPHIC DETAILS
Table 1
ADHD without SLD ADHD with SLD p-value
n Mean SD n Mean SD
Child Age 40 8.5 1.76 40 8.65 1.45 0.678
IQ 40 85.25 5.18 40 83.25 6.74 0.141
Father Age 40 34.5 3.21 40 35.7 4.56 0.196
Mother Age 40 30.6 2.76 40 31.45 1.92 0.114
Table 1 shows sociodemographic profile of the study group.
The mean age of the groups are around 8 years and their mean IQ is
above 80 as per the study inclusion criteria. There is no significant
difference between the groups in age and IQ of the children. There is no
significant difference between the mean ages of their parents.
Table 2
ADHD without
SLD
ADHD with
SLD
Chi Square
test
n % n %
SexMale 28 70 25 62.5
0.478Female 12 30 15 37.5
Socioecono
mic Status
Low 13 32.5 16 400.485
Middle 27 67.5 24 60
Religion
Hindu 36 90 38 95
0.36Christian 2 5 1 2.5
Muslim 2 5 1 2.5
Mother
Tongue
Tamil 37 92.5 38 95
0.644Telugu 2 5 2 5
Urdu 1 2.5 0 0
Table 2 shows the sociodemographic profile of the two groups.
Though the males outnumber the females, there is no significant
difference between the groups. The upper middle and lower middle
socioeconomic status of the children are grouped together as middle
socioeconomic status. The upper lower and lower socioeconomic status
of the children are grouped together as low socioeconomic status. There
is no significant difference between the groups in socio economic status,
religion and mother tongue.
Table 3
ADHD without SLD ADHD with SLD
n Median n Median
Birth Order 40 2 40 2
Child Education Level 40 3 40 3
Table 3 shows the basic profile of the children in terms of birth order
and child education level.
The median birth order of both the groups belongs to 2nd birth order. The
median child education level in terms class or standard in school of both
the groups belongs to 3rd standard. All of them are studying in normal
school.
Medication status
All the children included in the study are either drug naïve or under
treatment. If under treatment, they are all on tablet atomoxetine 10mg or
less per day. On the day of interview and assessment, they are asked to
skip the drug. This is done to reduce the effect of drug on assessment.
Table 4
SLDADHD WITH SLD
n %
Reading 22 55
Writing 3 7.5
Arithmetic 4 10
Mixed 11 27.5
Table 4 shows the specific learning disability profile the ADHD with
SLD group.
Specific learning disability was identified by NIMHANS learning
disability battery and the predominant deficit was categorized as above.
Nearly 55 percent of the group comprised of reading disorder. 27.5
percent of children were suffering from mixed or nos type. 7.5 percent of
the children were suffering from writing type and 10 percent were
suffering from arithmetic type.
Table 5
Risk Factors
ADHD without
SLD
ADHD with
SLD
Chi Square
Test
n % n %
Genetic
Family H/O SLD 2 5 3 7.5 0.644
Family H/O
ADHD1 2.5 4 10 0.166
Prenatal
Maternal Smoking 0 0 0 0 NA
Maternal Alcohol 0 0 0 0 NA
Maternal cocaine 0 0 0 0 NA
Perinatal
Nature of Delivery
Normal 32 80 28 700.301
LSCS/OTHER 8 20 12 30
Preterm Delivery 10 25 11 27.5 0.799
Low birth weight 3 7.5 4 10 0.692
Post Natal
Developmental
delay3 7.5 4 10 0.692
Table 5 shows the risk factors for ADHD and SLD.
There is no significant difference between the groups.
Table 6
ADHD WITHOUT
SLD
ADHD WITH
SLD p-
ValueMEAN SD MEAN SD
Inattention 2.11 0.42 2.56 0.47 0.0001
Hyperactivity/imp
ulsivity2.67 0.31 2.78 0.35 0.1408
Table 6 shows the mean SNAP IV ADHD severity rating scale score.
The mean ADHD inattention score for ADHD with SLD is slightly
higher than the ADHD without SLD group and the difference of mean is
found to significant.
The mean ADHD Hyperactivity/Impulsivity score for ADHD with SLD
group is higher than the ADHD without SLD group. But the difference of
mean between the groups is not found to be significant.
ADHD with comorbid SLD is found to be significantly more inattentive
than pure ADHD alone.
Table 7
Stroop Test
ADHD WITHOUT
SLD
ADHD WITH
SLD p-
Value
MEAN SD MEAN SD
Reading 174.35 26.15 276.45 77.65 0.001
Naming color 422.25 84.55 545.65 98.55 0.001
Stroop Effect
Score247.9 58.4 269.2 20.9 0.001
Table 7 shows the neuropsychological performance of the two groups in
Stroop Test.
The mean duration taken for reading the words and naming the color of
the word in stroop card is greater in ADHD with SLD group. The
difference between the two groups is found to be significant.
Stroop effect score, the difference of duration in reading and naming is
higher in ADHD with SLD group. The difference of mean between
groups is also found to be significant.
Table 8
Trail Making
Test
ADHD WITHOUT
SLD
ADHD WITH
SLD
p-
Value
MEAN SD MEAN SD
PART A 63.02 4.85 68.12 9.54 0.003
PART B 92.35 7.43 163.65 23.12 0.001
Table 8 shows the neuropsychological performance of the two groups in
Trail making Test
The mean duration for Part A of Trail Making test in ADHD with SLD
group is higher than the ADHD without SLD group. The difference
between the mean is also found to be significant.
The mean duration for Part B of Trail Making test in ADHD with SLD
group is higher than the ADHD without SLD group. The difference
between the mean is also found to be significant.
Table 9
Category
fluency
ADHD WITHOUT
SLD
ADHD WITH
SLD
p-
Value
MEAN SD MEAN SD
Animal naming 10.05 1.89 9.45 2.05 0.177
Table 9 shows the neuropsychological performance of the two groups in
category fluency test.
Animal naming is used for category fluency. The mean number of words
said by ADHD without SLD is higher than the ADHD with SLD. But
there is no statistical difference between the groups.
Table 10
N-back test
ADHD WITHOUT SLD ADHD WITH SLD
p-Value
MEAN SD MEAN SD
1-back hits 8.12 2.2 7.25 1.98 0.067
1-back errors 1.08 0.24 2.08 0.42 0.001
2-back hits 4.18 1.25 3.08 1.42 0.001
2-back errors 5.18 1.89 6.33 2.34 0.018
Table 10 shows the neuropsychological performance of the two groups
in Verbal N-Back test.
In both 1 Back and 2 Back verbal testing, the mean scores are greater for
ADHD without SLD group. The difference of mean is found to be
significant in all except 1-Back hits. In both tests, children committed
commission errors only. There were no omission errors. Omission errors
were more for ADHD with SLD group and it is found to be significant.
Table 11
CPT
ADHD WITHOUT SLD ADHD WITH SLD
p-Value
MEAN SD MEAN SD
Time taken 426.13 30.76 440.13 50.22 0.137
Errors 30.3 5.34 52.35 9.45 0.001
Table 11 shows the neuropsychological performance of the two groups
in Continuous Performance test.
Though the mean time taken for the test is slightly higher in ADHD with
SLD group, there is no significant difference between the groups.
The mean number of errors is slightly greater in ADHD with SLD group
and the difference is found to be significant. The errors committed by
children in both the groups are of omission type only.
Table 12
Untimed
movements
ADHD WITHOUT
SLD
ADHD WITH
SLD p-
ValueGait & stations MEAN SD MEAN SD
Right axial 1.08 0.41 1.15 0.32 0.397
Left axial 1.03 0.32 1.18 0.41 0.072
Total axial 2.11 0.39 2.33 0.38 0.187
Table 12 shows the untimed movements in gaits and station scores of
soft neurological signs in PANESS scale.
There is slight higher preponderance of soft neurological signs in ADHD
with SLD group. But the difference is not found to be statistically
significant.
Table 13
Untimed
movements
ADHD WITHOUT
SLD
ADHD WITH
SLD p-
ValueOverflow gaits MEAN SD MEAN SD
Right overflow 1.13 0.52 1.15 0.41 0.849
Left overflow 1.05 0.22 1.23 0.56 0.622
Total overflow 2.18 0.35 2.38 0.46 0.306
Table 13 shows the scores of soft neurological signs in PANESS scale
This table shows the untimed overflow gait scores in heel, toes and sides.
The mean scores for both sides are greater in ADHD with SLD. The
difference of mean between the groups is not statistically significant.
Table 14
Untimed
movements
ADHD WITHOUT
SLD
ADHD WITH
SLD p-
ValueMisc. &
involuntaryMEAN SD MEAN SD
Right 0 0 0 0 0
Left 0 0 0.08 0.27 0.607
Total 0 0 0.08 0.27 0.607
Table 14 shows the untimed miscellaneous and involuntary movement
scores of soft neurological signs in PANESS scale.
There is no significant difference between the groups.
Table 15
Untimed
movements
ADHD WITHOUT
SLD
ADHD WITH
SLD p-
ValueMEAN SD MEAN SD
Total gait and
stations4.29 0.36 4.79 0.41 0.214
Table 15 shows the total gait and stations in untimed movements.
Though the mean scores of soft neurological signs in untimed category is
greater in ADHD with SLD group, there is no statistically significant
difference between the groups.
Table 16
Timed
movements
ADHD WITHOUT
SLD
ADHD WITH
SLD p-
ValueOverflow MEAN SD MEAN SD
Right 0.13 0.33 2.08 0.26 0.001
Left 1.06 0.73 2.18 0.42 0.001
Total 1.19 0.50 4.26 0.32 0.001
Table 16 shows the timed overflow movements in PANESS scale.
The mean score for ADHD with SLD is greater than the ADHD without
SLD and the difference between the groups is statistically significant.
Table 17
Timed
movements
ADHD WITHOUT
SLD
ADHD WITH
SLD p-
ValueDysrhythmia MEAN SD MEAN SD
Right 1.05 0.32 2.13 0.42 0.002
Left 2.1 0.52 3.18 0.86 0.001
Total 3.15 0.4 5.31 0.64 0.001
Table 17 shows the timed dysrhythmia scores in PANESS scale.
The mean score for ADHD with SLD is greater than the ADHD without
SLD and the difference between the groups is statistically significant.
Table 18
Timed
movements
ADHD WITHOUT
SLD
ADHD WITH
SLD p-
ValueMisc. MEAN SD MEAN SD
Right 0 0 0 0 -
Left 0 0 0.15 0.43 0.164
Total 0 0 0.15 0.43 0.164
Table 18 shows the timed miscellaneous scores in PANESS scale.
The mean score for ADHD with SLD is greater than the ADHD without
SLD but the difference between the groups is not statistically significant.
Table 19
Timed
movements
ADHD WITHOUT
SLD
ADHD WITH
SLD p-
ValueSFA scores MEAN SD MEAN SD
Right 1.15 0.21 1.3 0.32 0.015
Left 3.1 0.32 3.98 0.22 0.001
Total 4.25 0.25 5.28 0.26 0.001
Table 19 shows the timed SFS scores in PANESS scale.
The mean score for ADHD with SLD is greater than the ADHD without
SLD and the difference between the groups is statistically significant.
Table 20
PANESSADHD WITHOUT SLD ADHD WITH SLD
p-ValueMEAN SD MEAN SD
Total gaits &
stations4.29 0.44 4.79 0.65 0.001
Total right
overflow1.26 0.40 3.31 0.32 0.001
Total left
overflow2.11 0.45 3.41 0.49 0.001
Total overflow 3.37 0.41 6.72 0.39 0.001
Total timed 8.59 0.39 15.00 0.55 0.001
Total PANESS 12.88 0.43 19.79 0.63 0.001
Table 20 shows the final scores of PANESS scale.
The mean score for ADHD with SLD is greater than the ADHD without
SLD and the difference between the groups is statistically significant.
Table 21
INATTENTIONr to z
transform
ationTest Measure
ADHD
WITHOUT
SLD
ADHD WITH
SLD
r r p value
Stroop testEffect
score0.34 0.45 0.576
TMTPart a 0.41 0.44 0.875
Part b 0.48 0.62 0.384
Category
fluency
Animal
naming-0.2 -0.21 0.968
N back test
1-hits -0.07 -0.11 0.865
1-error 0.32 0.44 0.549
2-hits -0.12 -0.17 0.826
2-errors 0.33 0.42 0.653
CPTTime 0.22 0.21 0.96
Errors 0.52 0.67 0.316
Table 21 shows the correlation between the inattention severity in both
the groups and their neuropsychological performance.
There is a positive correlation between inattention scores and stroop test,
TMT, CPT and N-Back test error scores. There is a negative correlation
between the inattention scores and category fluency and N-Back test hit
scores.
The scores imply that severe the inattention component, poorer the
performance in neuropsychological testing.
The trend is similar in both the groups with slightly greater coefficient
ratio in ADHD with SLD group. But the difference in correlation
coefficient is not statistically significant.
The correlation coefficient value in each group is also not high enough to
mention for clinical significance, except for TMT and Stroop effect score.
Table 22
HYPERACTIVITY/IMPULSIVI
TY r to z
transfor
mationTESTMEASUR
E
ADHD
WITHOUT
SLD
ADHD WITH
SLD
r r p value
Stroop testEffect
score0.22 0.27 0.818
TMTPart A 0.37 0.32 0.811
Part B 0.36 0.35 0.961
Category
fluency
Animal
naming-0.08 -0.16 0.726
N back test
1-hits -0.11 -0.12 0.968
1-error 0.27 0.37 0.631
2-hits -0.09 -0.14 0.826
2-errors 0.27 0.41 0.497
CPTTime 0.2 0.22 0.928
Errors 0.47 0.51 0.818
Table 22 shows the correlation between the hyperactivity/impulsivity
(HY/IMP) severity in both the groups and their neuropsychological
performance.
There is a positive correlation between hyperactivity/impulsivity scores
and stroop test, TMT, CPT and N-Back test error scores. There is a
negative correlation between the inattention scores and category fluency
and N-Back test hit scores.
The scores imply that severe the hyperactivity/impulsivity component,
poorer the performance in neuropsychological testing.
The trend is similar in both the groups with slightly greater coefficient
ratio in ADHD with SLD group. But the difference in correlation
coefficient is not statistically significant.
The correlation coefficient value in each group is also not high enough to
mention for clinical significance, except for TMT and CPT error score.
Table 23
PANESS
INATTENTION
p
value
ADHD WITHOUT
SLD
ADHD WITH
SLD
r r
Total gaits &
stations0.42 0.38 0.898
Total right
overflow0.34 0.35 0.967
Total left overflow 0.42 0.38 0.823
Total overflow 0.36 0.35 0.985
Total timed 0.54 0.46 0.765
Total PANESS 0.36 0.32 0.824
Table 23 shows the correlation between inattention scores and PANESS
scores.
There is a positive correlation between the inattention severity and
PANESS scores. But there is no statistical significant difference between
the groups.
Table 24
PANESS
HYPERACTIVITY/IMPULSIVITY
p
value
ADHD WITHOUT
SLD
ADHD WITH
SLD
r r
Total gaits &
stations0.38 0.35 0.798
Total right
overflow0.36 0.40 0.767
Total left overflow 0.42 0.39 0.812
Total overflow 0.40 0.39 0.985
Total timed 0.52 0.49 0.765
Total PANESS 0.34 0.36 0.824
Table 24 shows the correlation between inattention scores and PANESS
scores.
There is a positive correlation between the hyperactivity/impulsivity
severity and PANESS scores. But there is no statistical significant
difference between the groups.
DISCUSSION
DISCUSSION
STUDY DESIGN
The study was a cross sectional observational study and the
evaluation was done after giving an appointment of their convenient time.
It helped in keeping all the subjects included in the study for detailed
assessment. Children cooperated well for assessment in single session.
SOCIODEMOGRAPHIC DETAILS
The sociodemographic details of the study group show no
significant difference between the groups. The mean age of children is
around 8 years and most of them were studying in 3rd standard in both the
groups. This shows the common age group and standard where ADHD is
being identified or being treated. The IQ of all children in the study is
around 84. This is in accordance with inclusion criteria, where child with
IQ<70 is not included. Though boys are more than the girls in both
groups, the groups are comparable. The prevalence of ADHD in boys is
greater than females and accordingly the boys are more in our study(81).
The family`s socioeconomic status and religion had no difference
between the groups. Mother tongue also showed no difference. Only one
child`s mother tongue was Urdu and she was comfortable in Tamil and
English.
SPECIFIC LEARNING DISABILITY
ADHD children with specific learning disability were analyzed
using NIMHANS learning disability battery and grouped based on their
major disability.
Majority of the children belonged to reading disorder. Followed by
mixed or learning disorder nos type, arithmetic and written expression.
The prevalence is similar to other studies in ADHD with comorbid
SLD(51).
RISK FACTORS
There are numerous factors proposed as risk or causative factor for
ADHD and SLD. We have taken few risk factors for analysis in this
study. Most of the data are historical and few have recorded evidence.
The factors have been grouped as genetic and environmental factors
(Prenatal, Perinatal and Postnatal). Prematurity and Low birth weight are
associated with ADHD and SLD in numerous studies(22,82).
In our study, though few cases have risk factors for ADHD and
SLD, the difference between the groups is not significant. Some of the
factors seem to be irrelevant in Indian population. No cases are found to
have history of smoking and alcohol abuse in mother. Similarly lead
exposure and diet theory of ADHD cannot be evaluated.
Family history of ADHD or SLD is found to be positive in 10 out
of 80 children in total. All the positive family history children had ADHD
or SLD in either father or mother. History is inconclusive for other
relatives of proband. So they were neglected.
ADHD SEVERITY
The results are similar to previous studies(12,83,84). There is
statistically significant difference between the groups in inattention
category. Inattention score for ADHD with SLD is greater than the
ADHD without SLD. SLD without ADHD are found to have inattention,
though not up to the level of classifying it as ADHD. So ADHD with
SLD are found to have more inattention. The hyperactivity scores show
no difference between the groups.
NEUROPSYCHOLOGICAL PERFORMANCE
STROOP TEST
Stroop test measures attention and set shifting process. The
inattention scores for ADHD with SLD are significantly greater than
ADHD without SLD. Hence in stroop test, ADHD with SLD children
performed poorly and there is significant difference between the groups.
Stroop Test has been extensively studied in ADHD alone and along with
SLD. It was found that ADHD with SLD performed poorly than ADHD
alone(41,81,85). Our study confirms the previously stated findings.
TRAIL MAKING TEST
Trail Making Test part A measures the attention span, speed of
processing, motor control. Part B measures the set shifting ability along
with the above functions. Few studies have measured executive function
by subtracting Part b score from Part A.
Here there is no difference between groups in Part A of TMT. But
there is a significant difference between the groups in Part B. Part B
requires frequent shift in norm and attention. The results are similar to
previous studies(86).
CATEGORY FLUENCY
Category fluency measures the verbal fluency. Here animal naming
category is used to assess the verbal fluency. Children with ADHD had a
leeway in applying relevant lexical or executive strategies related to
difficulties in strategy using. The reduced efficiency of children with
ADHD in semantic fluency task is based on suboptimal shifting between
word clusters and is related to the lack of ability of producing new
clusters of items(65,71,87). But in our study, no difference was found
between the groups.
VERBAL N BACK TEST
Verbal N Back test measures short term memory / working
memory. Verbal working memory is impaired in specific learning
disability, especially for serial working memory. Compounded by
inattention, verbal memory is impaired in ADHD with SLD. There is
significant difference between the groups in all categories, except 1-Back
Hit. Similar to other studies, ADHD with SLD performed poorly
(78,88,89).
CONTINUOUS PERFORMANCE TEST
Continuous performance test measures the attention, impulsivity /
response inhibition and speed of processing. ADHD with SLD made
significant omission errors. There is no difference between the groups for
total time taken. Our finding is similar to previous studies done
before(42,70,90,91).
CORRELATION BETWEEN ADHD SEVERITY AND
NEUROPSYCHOLOGICAL PERFORMANCE
Deficits in working memory and inhibitory control arising from
dysfunction in the prefrontal cortex are stated in many
studies(67,78,88,92). Attention-deficit/hyperactivity disorder has been
associated with a prominent disturbance of executive functions. There is
no pathognomic neuropsychological profile for the disorder, however.
Nonetheless, results of neuropsychological testing, in concert with other
clinical information, provide a more comprehensive and detailed picture
of the individual patient's cognitive and emotional strengths and
weaknesses than a psychiatric diagnostic interview alone. This approach
to the evaluation of ADHD therefore can provide a strong objective basis
from which to make patient-specific recommendations for compensatory
strategies and treatment.
It should be noted, however, that although executive dysfunction in
the form of impaired response inhibition remains the most prominent
cognitive theory of ADHD, other theories have been put forth that also
deserve further investigation. These include a disturbance in delay
aversion (referring to intolerance for waiting) and impaired temporal
processing, among others.
The neural substrates of executive dysfunction in ADHD have
begun to be revealed by a growing body of structural and functional
neuroimaging research(11,83,93,94). Although still in its infancy,
neuroimaging of ADHD is pointing toward disruption of FSTC circuitry
and the cerebellum as being central to the cognitive and motor
abnormalities seen in the disorder. Further research using cognitive tasks
assessing executive functions in combination with functional imaging
techniques will provide further insight into the etiology of the disorder.
It is expected that advances in structural and functional
neuroimaging will yield valuable information that will facilitate the
differential diagnosis of ADHD. Evidence cited suggests that
psychostimulant medication can improve executive functions and their
underlying FSTC circuitry(5,32,35,95).
Furthermore, a recent study of adults with ADHD found significant
improvements in organization skills and other symptoms of ADHD
following cognitive remediation targeting several executive and
emotional aspects of the disorder(11). Additional studies investigating the
effects of treatment on executive dysfunction and brain integrity in
ADHD will be necessary to determine the degree to which the structural
and functional brain abnormalities observed are mutable.
Finally, because the myriad cognitive, behavioral and emotional
symptoms in ADHD likely reflect the interplay of multiple cognitive and
psychosocial factors, development of treatments for ADHD likely will
require a multi-modal approach.
Studies have mentioned the strong correlation between the severity
of disease with neurocognition by direct correlation and studies have
mentioned improvement in cognitive domains after reduction of
symptoms with treatment(32,42).
NEUROPSYCHOLOGICAL PERFORMANCE OF ADHD WITH
SLD
Children with both Attention-Deficit Hyperactivity Disorder
(ADHD) and SLD were found to have more difficulties with attention
span, processing speed and working memory(67,88,92). In our study,
though the correlation coefficient factor supports the above statement,
there is no significant statistical difference between ADHD with SLD and
ADHD without SLD.
NEUROLOGICAL SOFT SIGNS
NSS in young adults have been associated with a number of
neuropsychiatric and behavioral disorders, such as psychosis, obsessive-
compulsive disorder, and also in conditions of atypical development, like
autism and learning disability and ADHD(8).
NSS are known to be able to discriminate between abnormal and
normal group of children. Children with ADHD had significant overflow
movements and motor incoordination when compared to SLD alone.
Children with problems such as ADHD, SLD or academic under
achievement had soft neurological signs at varying severity and type.
ADHD children had more overflow movements. This reflects cortical
immaturity. Timed overflow, speed of movement and dysrhythmia are
significant factors in differentiating ADHD with SLD from ADHD
without SLD(96).
Our study shows significant difference between the groups in timed
overflow and dysrhythmia scores. The final component outcome scores of
PANESS scale also shows significant difference between the groups.
CORRELATION BETWEEN ADHD SEVERITY AND
NEUROLOGICAL SOFT SIGNS
Few studies have found correlation to be positive between ADHD
severity and soft neurological signs(96). Our study also finds it to be
positive, though not significant clinically. There is no significant
difference between the groups, when correlation factors are compared.
CONCLUSION
CONCLUSION
1. Inattention is significantly higher in ADHD with SLD than ADHD
without SLD as measured by neurocognitive assessment.
2. Timed Overflow and timed Dysrhythmia are significantly higher in
ADHD with SLD than ADHD without SLD
3. Soft neurological signs are significantly higher in ADHD with SLD
than ADHD without SLD.
4. SLD and ADHD sharing common neural substrates with more
brain dysfunction if SLD is a comorbidity in ADHD
5. Severe the ADHD score, poorer the cognitive performance.
6. Severe the ADHD score, more the soft neurological signs
7. Soft neurological signs and cognitive performance can predict the
severity of illness.
LIMITATIONS
1. Study Design
Inclusion of controls would have made the study more valid.
Instead of naturalistic cross sectional design, drug naïve children
and a prospective analysis with treatment would make the study
more reliable.
2. Sample Selection
ADHD with other comorbid disorders were included in the study,
which might have confounded the results.
Effect of medication would have confounded the results
3. The present study was limited with a relatively small sample size,
which precluded comparisons according to sex and age of children.
4. The normative data for the PANESS was not of Indian children and
could not be used for analysis.
FUTURE DIRECTIONS
Further research with large sample size and avoiding the said limitations
is needed to understand the implications of soft neurological signs and
cognitive performance of ADHD children in clinical setting.
Prospective study of severity of soft neurological signs in ADHD to
predict its influence on fine motor performance in future is needed.
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78. Katz LJ, Brown FC, Roth RM, Beers SR. Processing speed and working memoryperformance in those with both ADHD and a reading disorder compared with thosewith ADHD alone. Arch Clin Neuropsychol [Internet]. 2011 Aug [cited 2014 Sep22];26(5):425–33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21613301
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81. Bálint S, Czobor P, Komlósi S, Mészáros A, Simon V, Bitter I. Attention deficithyperactivity disorder (ADHD): gender- and age-related differences in neurocognition.
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83. Cortese S. The neurobiology and genetics of Attention-Deficit/Hyperactivity Disorder(ADHD): what every clinician should know. Eur J Paediatr Neurol [Internet]. 2012Sep [cited 2014 Oct 5];16(5):422–33. Available from:http://www.ncbi.nlm.nih.gov/pubmed/22306277
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ANNEXURES
Proforma for Sociodemographic Details
Sociodemographic Data
Name
Age
Sex
Father Age
Mothers Age
Socioeconomic Status
Child`s Education
Religion
Mother Tongue
Birth order of the child
Risk Factors
Maternal Smoking
Lead Exposure
Maternal Anaemia
Alcohol/Illicit drugabuse
Labour Problem
Nature of Delivery
Delivery Complications
Prematurity
Birth Weight
Milestones
Information to Parent/Guardian
Title: “Neurocognition and neurological soft signs in children with attention deficithyperactivity disorder”Principal Investigator: Dr.J.KOMAL
Third Year, MD Psychiatry Post Graduate,Madras Medical College
Co-Investigator(if any):
Name of Participant:
Site : Institute of Child Health, Dept of Child Psychiatry, MMC, Chennai
You are invited to take part in this research. The information in this document is meant to help youdecide whether or not to take part. Please feel free to ask if you have any queries or concerns.
PURPOSE OF STUDY:
ADHD is the most common childhood behavioural disorder in children (5.2% of school-agepopulation globally). It is a neurodevelopment disorder with frontal lobe dysfunction, cerebellumhas also been implicated. Neurological Soft Signs are non-normative performance on aneurological examination of motor and sensory functioning in the absence of a focal lesion. Theyare indicators of delayed development of motor inhibition.NSS have been associated with anumber of disorders, such as psychosis, OCD, and also in conditions of atypical development,like autism and learning disability.Cognitive study in young children of ADHD is relevant for several reasons. First, cognitive testsmay contribute to the accuracy of the early identification of children at risk of ADHD and provideinformation about what difficulties exist. Second, this research yields information about thecognitive mechanisms that underlie the symptoms of ADHD.
Thus, the study was planned with the aim of studying neurocognition, neurological soft signs inchildren with ADHD and the correlation of neurocognition, neurological soft signs to type andseverity of ADHD and with the co-morbidity of specific learning disability.
The study designYour child will be interviewed at ICH, Department of Child Psychiatry OPD.
Study ProceduresThe study involves evaluation of neurocognition, neurological soft signs in children with ADHDand study the correlation of neurocognition, neurological soft signs to type and severity of ADHDand with the co-morbidity of specific learning disability for which we will be interviewing you
and your child with various questionnaires. You will be required to spare roughly an hour for aone-time interview during your visit to opd in the hospital.
Possible benefits to you –Your child is assessed for type and severity of ADHD, neurological soft signs and neurocognitionthat will help in treatment and management.
Possible benefits to other peopleThe results of the research may provide benefits to the society in terms of advancement ofmedical knowledge and/or therapeutic benefit to future patients.
Confidentiality of the information obtained from youYou have the right to confidentiality regarding the privacy of your medical information (personaldetails, results of physical examinations, investigations, and your medical history). By signingthis document, you will be allowing the research team investigators, other study personnel and theInstitutional Ethics Committee, to view your data, if required. The information from this study, ifpublished in scientific journals or presented at scientific meetings, will not reveal your identity.
How will your decision to not participate in the study affect you?Your decision not to participate in this research study will not affect your medical care or yourrelationship with the investigator or the institution. You will be taken care of and you will notlose any benefits to which you are entitled.
Can you decide to stop participating in the study once you start?The participation in this research is purely voluntary and you have the right to withdraw from thisstudy at any time during the course of the study without giving any reasons. However, it isadvisable that you talk to the research team prior to stopping the treatment/discontinuing ofprocedures etc.
Signature of Investigator Signature of Participant(parent)
Date Date
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Informed consent form
Title of the study – “Neurocognition and neurological soft signs in children with attentiondeficit hyperactivity disorder”
Name of the participant: ____________________________________________
Name of the Principal/Co-Investigator: DR. J.KOMAL
Name of the Institution: Institute of Child Health, Dept of Child Psychiatry, MMC
Name and address of the sponsor / agency (ies), if any: _____________________
I,___________________(parent/guardian of participant), have read the information in this form(or it has been read to me). I was free to ask any questions and they have been answered. I amover 18 years of age and, exercising my free power of choice, hereby give my consent that mychild/ward be included as a participant in the study about the – Neurocognition and neurologicalsoft signs in children with attention deficit hyperactivity disorder.
(1) I have read and understood this consent form and the information provided to me.(2) I have had the consent document explained to me.(3) I have been explained about the nature of the study.(4) I have been explained about my rights and responsibilities by the investigator.(5) I have informed the investigator of all the treatments I am taking or have taken in the past,including any native (alternative) treatments.(6) I am aware of the fact that I can opt out of the study at any time without having to give anyreason and this will not affect my future treatment in the hospital.(7) I hereby give permission to the investigators to release the information obtained from me andmy child as result of participation in this study to the regulatory authorities, Governmentagencies, and ethics committee. I understand that they may inspect my original records.(8) I understand that my identity will be kept confidential if my data are publicly presented.(9) I have had my questions answered to my satisfaction.(10) I consent voluntarily to participate as a participant in the research study.I am aware, that if I have any questions during this study, I should contact the investigators. Bysigning this consent from, I attest that the information given in this document has been clearlyexplained to me and understood by me. I will be given a copy of this consent document.
Name and signature / thumb impression of the parent/guardian(Name of parent) __________________________(Signature)___________________ Date:__________
Name and signature of impartial witness (required for illiterate patients):(Name) ________________________________ (Signature) _____________________ Date__________Address and contact number of the impartial witness: _________________________________
Name and signature of the Investigator or his representative obtaining consent:
(Name) ________________________________ (Signature) ___________________ (Date)__________
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